Medicare Program Integrity Manual (CMS Pub. 100-08), Ch. 3 The Medical Review (MR) Program is designed to promote a structured approach in the interpretation and implementation of Medicare policies.
What is the role of the CMS Medical Review?
One distinct role of the CMS Medical Review personnel is to provide contractor oversight such as: Providing broad direction on medical review policy. Review and approve Medicare Contractors' annual medical review strategies. Facilitate Medicare Contractors' implementation of recently enacted Medicare legislation.
Who conducts the medical reviews for Medicare?
(See sources of Medicare requirements, listed below). Who conducts the medical reviews? Medicare Fee-for-Service (FFS) reviews are conducted by Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractors (RACs), and others.
How does the Medicare review process work?
The Medicare review contractor shall assess such claims to see if they qualify for a general or case-by-case exception to this generalized instruction, which would make the claim appropriate for Medicare Part A payment, assuming all other requirements are met.
What is a Medicare claim review?
A Medicare contractor may use any relevant information they deem necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request. (See sources of Medicare requirements, listed below). Who conducts the medical reviews?
What does it mean to be medically reviewed?
Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements.
What is the purpose of reviewing a patient medical record?
In medical record review, researchers simply review patients' medical records to discover patterns that help doctors make decisions about patients' medical care. For example, they might track what medications doctors prescribed and how well patients responded.
Which is a review of medical necessity?
Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission. Concurrent reviews include a review of medical necessity decisions made while the patient is currently in an acute or post-acute setting.
What agency reviews documentation and billing of Medicare services?
CERT performs a complex medical review of the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, payment, coding, and billing rules.
How do you review a patient?
Reviewing patients on callThe importance of reviewing patients. ... Ask for the basics while youre on your way. ... Make a rapid initial assessment. ... Look at the observations chart. ... Review the notes. ... Take a focused history. ... A full and formal examination. ... Putting it all together.More items...•
What is a record review?
A Record Review (RR) involves a dictated thorough review of an individual's medical records and other relevant information focusing on the disease development, injury mechanism, past medical and surgical history, prior diagnostic study results, and type of treatment the individual has received, along with outcomes of ...
What is an example of a medical necessity?
The most common example is a cosmetic procedure, such as the injection of medications, such as Botox, to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.
Which procedure does not meet the criteria for medical necessity?
To control health care costs by limiting physician payments. Which procedure does NOT meet the criteria for medical necessity? The procedure is elective.
What causes a Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What is a focused medical review?
fo·cused med·i·cal as·sess·ment. (fō'kŭst med'i-kăl ă-ses'mĕnt) Physical examination of a prehospital patient that focuses on body areas and systems as indicated by the patient's chief complaint and initial assessment.
How do you write a good medical review article?
2:0414:17How to write an review article ? Definition, structure and step wise ...YouTubeStart of suggested clipEnd of suggested clipYou need to have minimum amount of 30 to 50 a research article in order to write a review article.MoreYou need to have minimum amount of 30 to 50 a research article in order to write a review article. So there can be two type of review articles where in a general like concept you find a research cap.
Set Up Clinicient to Track the Medicare Therapy Threshold
To track the Medicare Therapy Threshold, the payer must have the setting Claim Type set to either Medicare-A (UB-04) or Medicare-B (CMS-1500). This setting makes it possible to enter a Medicare Therapy Threshold dollar total when setting up a patient’s payer mix.
Tracking a Patient through the Manual Medical Review Process
Reconfirm the patient’s eligibility. Let’s follow Fredric Goethe, a 64-year-old Medicare patient, through the Manual Medical Review Process. On September 25th, the front desk checks the eligibility and learns that $2604.23 of benefits has been used toward the Medicare Therapy Threshold.
Other Useful Tools
It is good to make sure that Clinicient has the correct Phase information Clinicient has integrated the therapist, Clinic or Company NPI phase information into the application to help with identifying when to submit patients for exception. But, this is based on what we know from payer settings and therapist credentialing.
I. Background
President Obama signed the American Taxpayer Relief Act of 2012 (Act) into law on January 2, 2013. The Act extended the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013.
III. RACs Are Now Conducting the Manual Review Process
CMS originally directed Medicare Administrative Contractors (MACs) to conduct prepayment review on all claims reaching the $3,700 threshold for claims processed between January 1, 2013 to March 31, 2013. CMS requested MACs conduct these manual medical reviews within 10 days.
IV. Providers Seek Clarification on the RAC Prepayment Review Process
After RACs were given full authority to conduct the manual review process, many in the provider community expressed confusion as to the entire process. For example, AHCA President Mark Parkinson described the process as “bifurcated, confusing and wholly inappropriate.” Mr.
V. The Manual Medical Review Process Has Been Bungled
Under the Act, the Government Accountability Office (GAO) was tasked to report on the implementation of the manual reviews. Unfortunately, a recent GAO report highlights just how much of a struggle implementation has become.
VI. Conclusion
As this review reflects, CMS’s new manual medical review process has not been implemented with any sense of organization. Medicare Part B therapy providers are sure to feel the burden as the government attempts to correct this new system.
What is PPS in Medicare?
In 1998, Medicare began paying skilled nursing facilities (SNFs) under a Prospective Payment System (PPS). PPS payments are per diem rates based on the patient’s condition and determined through a CMS prescribed case-mix model and payment classification system. This classification is done by the use of a clinical assessment tool, the Minimum Data Set (MDS), and is required to be performed periodically according to an established schedule for purposes of Medicare payment. Each MDS represents the patient’s clinical status based on an Assessment Reference Date (ARD) and established look-back periods for the covered days associated with that MDS. Medicare expects to pay at the rate based on the most recent clinical assessment (i.e., MDS), for all covered days associated with that MDS. Medical review decisions are based on documentation provided to support the coding and medical necessity of services recorded on the MDS for the claim period billed. Medicare contractors focus on the unique, individualized needs, characteristics and goals of each patient, in conjunction with CMS payment policies, to determine the appropriateness of the case-mix classifier billed.
What is DRG validation?
The validation is to verify the accuracy of the hospital's ICD coding of all diagnoses and procedures that affect the DRG.
Why do speech pathologists use KX modifiers?
The speech-language pathologist's use of the KX modifier is an attestation to CMS that services are medically necessary and justification of the need for services above the threshold is documented in the medical record. If CMS finds that documentation does not support ...
Can a claim be reviewed under the targeted medical review threshold?
Under the targeted medical review threshold, claims will not be reviewed unless the provider meets the criteria for review. These criteria are the same criteria applied to therapy services since 2015 and established by the Medicare Access and CHIP Reauthorization Act (MACRA).
Can you use KX modifier on a claim?
The KX modifier can be included with claims prior to reaching the $2,110 trigger because the patient’s current accrued claims amount cannot be known for certain due to claims submitted by other providers. However, it should not routinely be used with claims significantly before reaching the trigger.
Is the GN modifier necessary for speech pathology?
are reasonable and necessary services that require the skills of the speech-language pathologist; are justified by appropriate documentation. The use of the GN modifier to identify speech-language pathology services is still required, in addition to the K X modifier.
What is the Medicare Managed Care Manual?
(Chapter 4, §20.6 of the Medicare Managed Care Manual)All beneficiaries must be provided all medically necessary benefits covered in the plan in which they enroll (including supplemental benefits) at the time of their initial enrollment. Waiting periods or exclusions from coverage, due to pre-existing conditions, are not permitted. However,
Why is CMS redesigning Medicare?
In an effort to make the coverage process more open, understandable, and predictable, CMS has redesigned its Medicare coverage process. Part of the redesign includes using the Internet to inform interested parties about how national coverage determinations are made and the progress of each issue under coverage review.
What are advance directive requirements for Medicare?
The Medicare cost plan program’s advance directive requirements, which Fee-For-Service providers have been following for some years, are guidelines, which refer to state law, whether statutory or recognized by the courts of the State. Therefore, Medicare cost plans must comply with the advance directive requirements of the states in which they provide services. The CMS cannot give detailed guidelines as to what constitutes best efforts in each state. Medicare regulations give Medicare cost plans and states a great deal of flexibility, and CMS is prepared to work with the HMO and CMP (and the state, if needed) to ensure that advance directive requirements conform to Federal law.
What is Medicare coverage policy?
Medicare coverage policies specify which benefits are provided under the Medicare program and under what circumstances (including the clinical criteria under which the item or service must be provided). Medicare coverage policies have several sources:
What does "drug" mean in Medicare?
(Chapter 4, §20.9 of the Medicare Managed Care Manual) For this subsection, the term “drug” means “drug or biological.” As indicated in §10.1, a Medicare cost plan must provide its enrollees with coverage of all drugs covered under original Medicare Part B. Part B Medicare covers drugs in a limited number of cases including the following:
What is a chiropractor covered by Medicare?
Section 1861(r) of the Social Security Act provides the definition of a physician for Medicare coverage purposes, which includes a chiropractor for treatment of manual manipulation of the spine to correct a subluxation. (As a standard Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees of cost plans.) The statute specifically references manual manipulation of the spine to correct a subluxation as a physician service. Thus, Medicare cost plan organizations offering cost plans must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation. Medicare cost plans may continue to use physical therapists to treat enrollees for conditions not requiring physician services as defined in §1861 (r) of the Social Security Act.
How does Medicare cost plan work?
The Medicare cost plan must furnish a copy of the rules to each Medicare enrollee at the time of enrollment and at least annually thereafter. If a Medicare cost plan changes its rules, it must submit the changes to CMS in accordance with proper procedure and notify its Medicare enrollees of the changes at least 30 days before the effective date of the changes.
